As mental health professionals, you may encounter clients suffering from treatment-resistant depression (TRD)—a condition affecting about 35% of those with depression who do not respond to at least two different antidepressants. Fortunately, innovative treatment strategies are emerging, particularly the combination of Ketamine and Transcranial Magnetic Stimulation (TMS). Recent research indicates that this duo may offer significant relief for patients who have not found success with traditional therapies.
Now, you may be wondering, what is Transcranial Magnetic Stimulation and how can it help with TRD? As researchers search for better ways to treat depression, it has been shown that biological interventions (altering the function of the brain by increasing neuroplasticity) are promising methods. Within the scope of biological interventions, TMS has been proven to be the most effective, least invasive, and encompasses the least amount of side effects. TMS induces a current in the cerebral cortex using electromagnetic impulses. It is effective in 30-90% of patients with TRD.
The other question that may be floating around your mind is how can ketamine help with TRD, isn’t ketamine an anesthetic? This is true, ketamine has been used in the medical world for decades. However, recent studies have shown that in subanesthetic doses, ketamine exhibits rapid anti-depressant properties. It is effective in up to 70% of patients.
This review aims to offer valuable insights into the rationale behind utilizing a combination of TMS and ketamine as a more effective treatment strategy, which could improve symptoms in patients suffering from treatment-resistant depression. To discuss potential synergy between TMS and ketamine, each method will be described individually, before we can find the benefits of their combination.
Transcranial Magnetic Stimulation for Treatment Resistant Depression
First, we will dive into the healing properties and mechanism of Transcranial Magnetic Stimulation. TMS has been in practice for nearly 40 years. The process involves generating an electromagnetic pulse using a coil placed on the scalp, which penetrates the skin and skull to stimulate the cerebral cortex. This stimulation can excite specific brain regions, leading to either an increase or decrease in neuronal activity, depending on the frequency of the pulses. Low-frequency stimulation (1 Hz or less) induces long-term depression (LTD), reducing neuronal activity, while high-frequency stimulation (5 Hz or greater) promotes long-term potentiation (LTP), enhancing excitability. These effects contribute to neuroplasticity, the brain’s ability to adapt and reorganize itself, which is crucial for learning and memory.
The therapeutic applications of TMS have been particularly promising in treating treatment resistant depression. Studies have shown significant mood improvements in individuals receiving repetitive TMS (rTMS) targeting the dorsolateral prefrontal cortex (dlPFC), an area of the brain often implicated in depression. With protocols recommending sessions to last several weeks, TMS has demonstrated a reduction in symptoms for a substantial number of patients. For instance, recent studies have reported success rates of up to 90% in symptom reduction with innovative protocols like Stanford Accelerated Intelligent Neuromodulation Therapy (SAINT), which utilize advanced techniques such as neuronavigation based on functional MRI results. Overall, TMS not only alleviates depressive symptoms but also reduces suicidal ideation, making it a critical option for patients with complex mental health challenges.
Ketamine for Treatment Resistant Depression
Next, we will discover why ketamine can be considered a viable treatment option for treatment resistant depression. Ketamine, first synthesized in 1963 as a dissociative anesthetic, has gained recognition for its therapeutic potential. In 2000, research revealed that intravenous administration of subanesthetic doses of ketamine could rapidly reduce depressive symptoms, with effects lasting up to 72 hours. Subsequent studies demonstrated a notable efficacy rate of 60-70% with a single dose, highlighting ketamine’s ability to provide quick relief—often within just 2 to 4 hours of infusion. However, while the initial effects are rapid, they tend to diminish relatively quickly, typically fading within a week after a single administration.
Clinical data further supports ketamine’s effectiveness, showing a positive response in approximately 44% of patients after multiple infusions. In addition to alleviating depressive symptoms, ketamine has been shown to reduce suicidal ideation and combat anhedonia, the inability to feel pleasure. Its unique mechanism of action, which differs from conventional antidepressants, positions ketamine as a promising alternative for those who are unresponsive to other treatments. This rapid and significant symptom relief underscores ketamine’s potential to be a game-changer in mental health care.
Understanding Neuroplasticity
Neuroplasticity refers to the brain’s ability to undergo structural and functional changes in response to experiences, learning, and environmental stimuli. First introduced by neurobiologist Jerzy Konorski 80 years ago, this concept fundamentally changed our understanding of the nervous system, which was once thought to be static. Neuroplasticity encompasses both adaptive changes that facilitate learning and maladaptive changes that can contribute to mental health disorders. The ongoing research into neuroplasticity has revealed its critical role in recovery from brain injuries, the treatment of mental health conditions, and the overall capacity of the brain to reorganize itself.
Both TMS and ketamine have been shown numerous times to promote neuroplasticity, which is likely responsible for their therapeutic effects. Plasticity-related changes are noted at different functional levels of the central nervous system, from changes in neurotransmission and neurotrophic factor levels, through genetic modifications, epigenetic changes, to alterations in brain structure and patterns of brain activity.
Combined Transcranial Magnetic Stimulation and Ketamine Treatment
While research in this field is still limited, the studies that are present show that the combination of repetitive transcranial magnetic stimulation with ketamine led to a substantial and sustained improvement of symptoms in all patients with treatment-resistant depression.
Helping Therapists Expand their Practice
At ATMA CENA, we are committed to empowering therapists to integrate these advanced treatment options into their practice. Our CoCare program offers comprehensive training and certification for professionals interested in providing ketamine and TMS therapies. By joining our program, you can enhance your therapeutic toolkit and offer your clients new age solutions for their mental health challenges. To learn more about the CoCare program and how to get certified, please book a free information call through our website. Together, let’s work towards transforming the lives of those affected by treatment-resistant depression.
